MOOD DISORDER DUE TO A GENERAL MEDICAL CONDITION

Case Study: Im Tired

by:

FATHMA SONNAYA M. MINAGA

MOOD DISORDER DUE TO A GENERAL MEDICAL CONDITION

Mrs. J, a 65-year-old widow of 2 years, visits her medical doctor because of increasing fatigue, lethargy, and depression that have developed over the past 6 months. These symptoms began gradually, but over the past month have worsened to the point that she is having trouble getting out of bed in the morning, quit her volunteer job at the local hospital, and stopped a number of her usual social activities at church. She does not seem to have any motivation, and it has become a chore to perform even the most basic activities of daily living, such as cooking and housekeeping. Mrs. J reports that she has been sleeping too much (sometimes 10-12 hours per day) and has gained weight (15 pounds over the past month) because of inactivity. She also complains of diffuse aches and pains, difficulty staying warm, and a range of other physical discomforts. Other family members have recently remarked about how tired and fatigued she looks. Mrs. Js daughter is very concerned because her mother has dropped out of so many activities that she formerly enjoyed and does not even show much that interest in spending time with her two young grandchildren, to whom she has always been devoted. Mrs. J is very upset about feeling so tired all the time. She reports that she is frequently tearful and is beginning to feel that she is a burden on the daughter with whom she lives. Most of the household chores that she used to help with now fall on her daughter, who also cares for her two small children and husband. Mrs. J says she has started wondering whether she wouldnt be better off dead so that I wouldnt be a burden on everyone. Mrs. J reports that her concentration has worsened over the past couple of months, that she frequently misplaces things, and that she even has difficulty following the plot of television programs.

Mrs. J has no history of depression, excessive Alcohol Use, or problems with memory before 6 months ago. She has never been hospitalized for psychiatric problems, nor there any family history of such problems. She has seen a mental health professional only once for a short period of psychotherapy following the death of her husband. She says that she thinks of her husband often and continues to miss him because they were happily married for 48 years and had a satisfying and fulfilling relationship. Mrs. J says that she had just begun to feel some relief from that loss when this feeling of fatigue and the blues started. She has also experienced a number of new physical health problems since her husbands death and has been diagnosed with both diabetes and hypertension within the past year. Mrs. J is currently taking glyburide 5mg/day for diabetes and hydrochlorothiazide 50mg/day for hypertension. Over the past 6 months. She has also experienced worsening constipation for which she takes a stool softener (docusate sodium 100mg) twice a day and occasionally gives herself an enema to obtain relief.

Upon physical examination, Mrs. J is afebrile with a pulse of 55, blood pressure of 120/80, and respirations of 14 per minute. Her face appears a bit swollen, and there is edema in both lower extremities. Neurological exam is nonfocal, and reflexes are symmetrical but slowed. Otherwise, the physical exam is normal.

During the initial interview, Mrs. J appears tired, listless, and older than her stated age. She describes her mood as depressed and discouraged. She says this is because she is so tired and cant do the things she used to be able to do. Her affect is somewhat constricted and depressed, but her eye contact is good and she relates well to the therapist. Her speech is slowed but spontaneous and friendly in tone. Her thought processes are goal directed and logical. Her thought content is characterized by ruminations about her fatigue and difficulties with usual activities, but no hallucinations and delusions are present. Mrs. Js concentration is mildly impaired on formal testing, but the impairment is not as severe as she initially indicated. Her judgement, ability to abstract, and insight are all intact. Initial laboratory testing reveals normal electrolytes, blood glucose, complete blood count, and vitamin B12 level. Her electrocardiogram and a head magnetic resonance imaging (MRI) scan are also normal.

The clinician initially concludes that Mrs. J is depressed over the loss of her husband and her physical health problems and places her on fluoxetine 20mg/day. However, when she returns in 1 month, she says that she does not feel any better and that, although she is sleeping less, she is also feeling shaky and anxious. The fluoxetine is reduced to 10mg/day, and a thyroid panel is drawn. Later that week, the thyroid studies reveal a T-4 of 3.5 and a TSH of 15.

Mrs. J is then placed on a dose of levothyroxine 0.05 mg/day, which is increased to 0.1 mg/day after 2 weeks. After 1 month of treatment, Mrs. J begins her energy returning amd a gradual improvement in her mood and outlook. She resumes her volunteer work at the hospital and her previous activities at church. After 3 months of treatment, Mrs. J is back to her usual self. The fluoxetine is then discontinued and, when followed up 2 years later, Mrs. J has not experienced any recurrence of symptoms.

DSM-IV TR Diagnosis
Axis I 293.83 Mood Disorder due to Hypothyrodism, with Major Depressive-Like Episode Axis II V71.09 No diagnosis Axis III 244.9 Hypothyrodism 250.00 Diabetes mellitus, noninsulin dependent 401.9 Hypertension Axis IV Inability to perform day-to-day social and housework activities Axis V GAF = 40 (at time of initial evaluation); 80 (at follow-up)

DSM-IV TR diagnostic criteria for 293.83 Mood Disorder Due to [Indicate the General Medical Condition]
A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following: (1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities (2) elevated, expansive, or irritable mood There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. The disturbance is not better accounted for by another mental disorder (e.g., Adjustment Disorder With Depressed Mood in response to the stress of having a general medical condition). The disturbance does not occur exclusively during the course of a delirium. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

B.

C.

D. E.

Specify type:
With Depressive Features: if the predominant mood is depressed but the full criteria are not met for a Major Depressive Episode With Major Depressive-Like Episode: if the full criteria are met (except Criterion D) for a Major Depressive Episode With Manic Features: if the predominant mood is elevated, euphoric, or irritable With Mixed Features: if the symptoms of both mania and depression are present but neither predominates Coding note: Include the name of the general medical condition on Axis I, e.g., 293.83 Mood Disorder Due to Hypothyroidism, With Depressive Features; also code the general medical condition on Axis III. Coding note: If depressive symptoms occur as part of a preexisting Vascular Dementia, indicate the depressive symptoms by coding the appropriate subtype of the dementia if one is available, e.g., 290.21 Dementia of the Alzheimer's Type, With Late Onset, With Depressed Mood.

Guidelines for Differential Diagnosis of a Mood Disorder Due to a General Medical Condition
1. Take careful medical history, including a drug and medication history, being alert to any conditions or substances that are known to physiologically induce a depressive-like state. Careful physical and neurological examinations should follow, along with a complete laboratory evaluation that includes thyroid studies, serum vitamin B12 level, serum chemistries, a complete blood count, and if indicated, tests for syphilis and acquired immunodeficiency syndrome (AIDS). A head MRI may be helpful in cases of head injury, when the neurological exam is positive, or of an elderly patient with a new onset of psychopathology with no history of psychiatric symptoms.

2. Be alert to the time course of depressive symptoms in relationship to the onset of the physical illness. Symptoms that represent a direct physiological consequence of the medical illness usually (but not always) appear either just before physical manifestations of the disease (as with pancreatic cancer) or concurrently with the physical health problem (hyperthyroidism). Depressive symptoms that are a reaction to a medical condition and resolve with improvements in functional status. If a primary Depressive Disorder is present, depressive symptoms will usually persist even after the medical illness improves. It should be noted that depressive symptoms may sometimes precede the onset of a primary medical illness, and the symptoms may persist after it has been treated.

3. When depressive symptoms appear in the setting of physical illness, give greater weight to the presence of the affective or cognitive symptoms of depression, which are less likely to be confused with the somatic symptoms of a general medical illness. Examples of affective or cognitive symptoms include depressed mood, loss of interest, diminished ability to experience pleasure, insomnia, feelings or worthlessness or being a burden, tearfulness or crying, irritability, social withdrawal, feeling punished, or wanting to die. Somatic symptoms that should receive less attention because they are often caused by a general medical condition include anorexia or weight loss, weight gain, fatigue, difficulty concentrating, hypersomnia, and psychomotor slowing. These symptoms are present in 30%-50% of patients with medical illness alone.

4. Ask patients whether they are experiencing stress in their personal life, having problems with family members, undergoing role changes, or struggling with unmet personal goals. If this is the case, then the likelihood of a psychological component to the depression is increased. However, this is fairly nonspecific because stress and psychological factors are ubiquitous and do not rule out or even reduce the likelihood of a medical illness.
5. Is there a personal or family history of problems with depression, nerves, or alcoholism? If so, these patients are at increased risk for depression during the stress of physical illness.

Treatment Planning for a Mood Disorder Due to a General Medical Condition

The first step in the treatment of a Mood Disorder Due to a General Medical Condition is to attempt to correct the underlying medical illness responsible for the problem. However, at times, such treatment is not completely successful in relieving the general medical condition or the consequent Mood Disorder. In these instances, an appropriate psychotic drug antidepressant or mood stabilizer may be helpful. Most people in the field today believe that depression is probably underdiagnosed and undertreated in the medically ill.

-ENDReported by:

FATHMA SONNAYA M. MINAGA